Every finding on record at Care Alternatives of Missouri, LLC

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/06/2025. The Skilled Nurse documented the comprehensive nursing assessment on 03/06/2025. The comprehensive assessment did not include documentation of an initial bereavement assessment. The Social Worker documented on a note dated 03/07/2025 "unable to contact patient's son, will complete bereavement assessment at first contact." There was no documented evidence in the clinical record that an initial bereavement assessment was completed for the patient’s family. During joint review of records and interviews on 07//16/2025 and 07/17/2025, the Clinical Director (Personnel Record 9) agreed the clinical record did not include documentation of an initial bereavement assessment being completed.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure hospice volunteers provided administrative and direct patient care services in an amount that equaled 5% of the total patient care hours of all hospice employees. Review of the agency’s 2024 Hospice Volunteer Requirement Report revealed that the volunteer percentage of hours worked for January 2024 through December 2024 was 0.52%. During an interview on 07/16/2025, the Volunteer Coordinator agreed that the 5% minimum was not met for 2024.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed with live discharge, the agency did not ensure the discharge summary was sent to the receiving facility or the attending physician. Agency policy PC. D20 Discharge from Hospice Care, required in part: " When the patient is discharged from hospice, the hospice provides a copy of the hospice discharge summary to the patient's attending physician. This discharge summary is filed in the clinical record and includes: the date of discharge, the reason for discharge, a summary of the patient's stay including treatments, and symptom and pain management, a copy of the patient's current plan of care, including the current drug profile, the patient's latest physician orders, and any other documentation that will assist in post-discharge continuity of care." CLINICAL RECORD 20: The patient elected the hospice benefit on 04/07/2025. The patient and family requested a revocation on 06/30/2025 to seek aggressive treatment. The patient was seen by the Registered Nurse on 06/30/2025 for a discharge visit. There was no documented evidence in the clinical record that a discharge summary was sent to the receiving facility or the patient’s attending physician. During joint review of records and interviews on 07//16/2025 and 07/17/2025, the Clinical Director (Personnel Record 9) agreed that the record did not include documentation that the discharge summary was sent.

Based on document review, policy review and interviews, the hospice failed to ensure hospice staff immediately reported and protected patients from an allegation of abuse. The cumulative effects of the hospices failure to ensure immediate employee reporting and protection of patients from abuse has the potential to place patients at risk for harm and for violation of their rights. --- Findings Include: 1. The hospice failed to ensure hospice staff immediately reported and protected patients from abuse for one of three records reviewed (Patient 2). (Refer to L508)

Based on document review, policy review and interviews, the hospice failed to ensure hospice staff immediately reported and protected patients from abuse for one of three records reviewed (Patient 2). The hospices failure to ensure immediate employee reporting and protection of patients from abuse has the potential to place patients at risk for harm and for violations of their patient rights. --- Findings Include: Review of a hospice policy titled, "Assessment of Possible Abuse/Neglect," Policy No. H: 2-054.3, Revised April 2018, showed any clinician who discovered any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor. This includes: Any knowledge of abuse or neglect. Review of Hospice Patient Rights and Responsibilities, showed each patient had a right to be free from mistreatment, neglect, verbal, mental, sexual, and physical abuse, corporal punishment, injuries of unknown source and misappropriation of property. All mistreatment, abuse, neglect, injury and exploitation complaints by anyone furnishing service on behalf of the Hospice are reported immediately by our staff to the administrator. Patient 2 Review of Patient 2's medical record showed the patient was admitted to hospice services on 11/17/ 22. The patient was an 84-year-old female with a primary diagnosis of Parkinson's disease and history of hallucinations, depression, anxiety, and vascular dementia who lived in an assisted living facility. Review of the Hospice Plan of Care dated for the Certification Period 11/17/22-2/15/23 showed Home Health Aide Services were ordered for the patient twice weekly to provide services listed on the Hospice Aide plan of care. Review of the ";HHA Plan of Care and Note" completed by Staff C on 01/12/23 showed personal care services were completed by the Home Health Aide. Review of hospice documentation dated 01/24/23 showed Staff B, Home Health Aide (HHA) assisted Staff C, HHA with her patients care at the assisted living facility on 01/12/23. Patient 2 was receiving personal care and was noted to be really agitated. Staff C was trying to redirect the patient by holding her hands/arms down and the patient was trying to bite her. Documentation showed Staff C, slapped the patient in the face. Staff B, HHA confirmed Staff C later asked the patient what was wrong with her, and the patient stated, ";You slapped me". During an interview on 02/09/23 at 10:10 AM, Staff B, HHA confirmed completing personal care services with Staff C, HHA for Patient 2 on 01/12/23. She confirmed the patient was agitated and Staff C was trying to redirect the patient by holding her hands when the patient tried to bite her. She confirmed that she turned to grab supplies and saw Staff Cs hand moving toward Patient 2s face and heard a slapping noise. She confirmed she did not see Staff Cs hand come directly into contact with patient 2s face. During the same interview Staff B, HHA confirmed that she did not immediately report the incident to her supervisor as she was unsure and concerned with getting her colleague in trouble. Staff B, HHA confirmed she reported the incident to her supervisors the next morning (01/13/23). During an interview on 02/09/23 at 10:30 AM, Staff A, Administrator confirmed she received the report from Staff B, HHA on 01/13/23 and began the investigation and reporting process. Staff A, administrator confirmed the patient was evaluated by professional staff and did not sustain physical injury.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (7%) clinical records revealed the agency did not ensure that the drug profile included oxygen, as ordered. Clinical Record 2 - Plan of care dated 4/27/2022 included orders for "oxygen 2-3L/min per NC PRN", and the recertification plan of care included orders for "oxygen 2-3 L via NC 24/7". Oxygen was not listed on the medication profile initiated on 4/27/2022, and updates to the medication profile through 9/28/2022 did not include oxygen on the medication profile. The Director of Nursing stated in part in an interview on 9/27/2022, "I am not sure why it is not there; it is supposed to flow over automatically". 1 of 13 (7%) of clinical records reveal that the agency did not ensure that the drug profile included oxygen as ordered.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) clinical records the agency did not ensure that the plans of care included complete orders for the care and services necessary to meet the patients' needs. Clinical Record 1 - The nursing assessment on 8/26/2022 stated the patient had an old surgical wound on the right knee, a stasis ulcer on inner left lower leg, and a stasis ulcer on inner left leg. The nursing visit note on 9/13/2022 stated in part: "Private duty wound nurse unavailable today. Right knee has chronic unhealed scope incision hole. Area cleansed, packed with iodoform, covered dressing." Nursing visit note dated 9/13/22 stated: "Left lower inner leg small stasis ulcer, cleansed and dressing reapplied. Left lower inner leg, small stasis ulcer - cleansed and dressing applied." There were no orders on the plan of care for the wound care being provided. In addition, a physician order dated 8/26/22 read: "Start 8/26/2022 New medication: Apply 1 gel of diclofenac sodium (diclofenac 1%) 4 x day. Medication Indication: Pain". The order did not include a description of the location where the gel was to be applied. Clinical Record 11 - The physician orders written 1/10/2022 read: "Start on 01/10//22 New medication: Apply 1 Gel of clobetasol (0.5%% Gel) topically 1x day. Dosage form: Gel [Until healed]" and "Start on 01/10/22 New Medication: Apply 1 cream of silver sulfadiazine (1% cream) topically 1 x day. Dosage form: Cream [Until healed}". There was no documentation in the order that described where the cream and gel were to be applied. The Director of Nursing and Director of Quality Education stated in part, in interview on 9/27/2022: "Nope, it is not there. We have been doing a lot of education about care plans and we are all excited to change software systems in December. 1 of 13 (7%) of clinical records revealed that the agency did not ensure that the plan of care included the care and services necessary to meet the patient's needs.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 11 (45%) relevant clinical records revealed that the agency did not ensure that the aide care plans provided specific written patient care instructions that would allow the aide to effectively complete all necessary patient care within the scope of their practice. Clinical Record 1 - SN Assessment on 8/26/2022 revealed the patient had an old open surgical wound on their knee and two stasis ulcers on lower leg. The aide care plan did not mention the wounds or give any direction to the aide related to washing or avoiding wound areas or instruction related to soiled or dislodged bandages. Clinical Record 2 - SN assessment on 4/27/2022 noted that the patient was short of breath and required oxygen via nasal cannula (NC). The plan of care dated 4/27/2022 included orders for "oxygen 2-3L per NC". The Aide care plan dated 4/27/2022 did not mention use of oxygen and gave no direction to the aide related to oxygen. Also, the SN note on 8/18/2022 revealed the patient had a new full thickness wound on the right lower leg with new orders received for wound care. The aide care plan was not updated to provide the aide with any direction related to care to the dressed wound area. Clinical Record 6 - SN assessment on 5/10/2022 noted that patient suffered from dysphagia and was placed on aspiration precautions. The care plan problem dated 5/15/2022 noted patient had airway clearance altered due to aspiration potential. The plan described dysphagia interventions with a goal to prevent aspiration and intervention to keep the patient upright at 90 degrees especially when eating. The aide care plan dated 5/11/2022 included seizure precautions and fall risk but did not mention aspiration precautions. The aide care plan did assign the aide to assist with feeding and offer fluids but did not include directions to keep the patient positioned upright at 90 degrees. Clinical Record 9 - Initial Plan of care dated 11/25/2020 contained orders for oxygen use "PRN", and the SN assessment dated 11/25/2020 stated that oxygen was ordered to be available for future exacerbation. The RN visit note dated 5/24/2022 stated the patient was now using oxygen 3-5 days per week with relief. The aide care plan was dated as updated and reviewed on 5/22/2022 but did not contain any instruction to the aide related to oxygen. Also, the aide care plan updated by the RN on 8/1/2022 did not contain instruction to the aide related to oxygen. Clinical Record 13 - SN assessment on 1/11/2022 revealed the patient chokes easily and is on aspiration precautions. The aide care plan dated 1/11/22 did not include aspiration precautions. The SN visit not dated 7/6/2022 stated the patient had a new pressure ulcer on the heel with dressing applied, however the aide care plan was not updated to include direction to the aide related to care to the heel dressing. During interview on 9/27/2022, the Director of Clinical Services stated, "I agree, I totally see that. Including those things on the aide care plan has not been on our radar and you may not see wound care or oxygen on aide care plans, but it makes sense why it should there." 5 of 11 (45%) relevant clinical records reveal that the agency did not ensure that the aide care plan provided written patient care instructions that would allow the aide to perform effectively within the scope of practice.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and observations. 2 of 11 (18%) relevant records revealed the agency did not ensure aides provided visits and services as ordered on the plans of care. Clinical Record 4 - Orders for hospice aide visits beginning the week of 5/24/2022 were "2 x week". During the week of 5/24/2022 through 5/28/2022, an aide visit was documented as completed on 5/25/2022 but there was no other visit completed that week. During the week of 5/29/2022 through 6/4/2022, an aide visit was documented as completed on 6/3/2022 but no other aide visit was completed that week. In addition, the aide visit note dated 6/7/2022 did not include a task list or any documentation related to the services provided during the visit. During an interview with the Executive Director, Director of Nursing and Clinical Educator on 9/28/2022, they stated that they have had trouble with the aide software interfacing with the clinical software and that was the only explanation for the task list not appearing on the aide visit note. Clinical Record 1 - The aide care plan dated 8/27/2022 assigned the aide to complete the following tasks: "gait belt transfer to chair/ geri chair/bed; bathroom assistance; incontinence care; offer fluids; assist with feeding at mealtime; play music, TV; take outside". The aide visit note dated 8/30/2022 revealed that aide did not document that those assigned tasks were completed during the visit. During an interview with the Administrator, Director of Clinical Services, and Regional Director on 9/27/2022, it was stated: "We see what you are seeing. We will be educating them on this issue". 2 of 11 (18%) of relevant records reveal that the agency did not ensure that the aide provided care and services ordered n the aide paln of care.